NHELSON JASMIN
Summary
Hardworking and motivated Medical Records Director with five years of experience in the SNF clinic. Dedicated to working closely with employees to maximize productivity and optimize procedures. Decisive leader with good planning and organizational skills.
Overview
6
6
years of professional experience
Work History
Medical Records Director
CALIFORNIA POST ACUTE
2023.03 - Current
- Check the census for admissions, discharges, and expirations
- Update the Admission/Discharge Register as necessary
- Review discharge records for completion
- Review expiration records for an order to release the body, mortician's receipt and comprehensive note describing events prior to expiration
- Monitor progress of admissions from the previous day
- Check telephone orders for: i
- Resident's name, room number ii
- Physician's name is listed iii
- Orders are complete
- Compare telephone orders against orders written on the Attending Physician's order, MAR/TAR and Care Plan, if applicable, to assure that they match
- Check if a new physician order is noted in the nurse's notes
- Complete the change in condition monitor
- Follow up with nursing to verify that lab/x-ray requisitions have been completed per schedule/order
- Review records if a physician has visited, to assure follow up
- Pull pharmacy copies once orders are signed
- Route to pharmacy within 48 hours of obtaining the Attending Physician signature
- File miscellaneous forms in records
- Complete monitors per schedule
- Follow up on records not returned or documentation needed from hospitals and physicians
- Complete, copy, and transmit discharge summaries to Attending Physicians
- Assemble records to be closed
- Copy and mail/fax items needing completion to physicians
- Route records to nursing and/or other disciplines for follow-up
- Update the Medicare Log and check records for timely completion of certifications/recertifications
- Review active resident records at nursing stations and archive documentation in overflow folder as appropriate.
Medical Records Specialist
PALAZZO POST ACUTE
2018.03 - 2023.03
- Maintain the health information service for the facility in accordance with current laws and regulations, and professional practice standards
- Develop, organize and maintain a current Master Resident Index
- Provide accurate ICD-CM codes, using current revision, to the appropriate departments timely
- Maintain an organized system for both in-house and discharged residents to facilitate records retrieval and access
- Process, audit, complete resident's discharge records within 30 days
- Maintain a system for the timely completion of the charts
- Audit current resident records for accuracy and completeness according to the established schedule
- Audit all admissions making sure all necessary documentations are completed
- Audit Medicare Skilled Nursing Notes, Weekly Summary, RNA/CNA ADL, Order Listing, COC, and EMAR on a daily basis prior to Stand up Meeting
- Follow up on Incomplete Audits from the previous day ensuring all documentations are timely and accurate
- Checking Dashboard and Communication tab for any changes such as Room Change, New COC, New Admissions, Change of Payer on a daily basis
- Scan and upload Employees Screen Tools, Stop and Watch, Doctor's Progress Notes, Resident's H&P, Acute Hospital Records in a timely manner
- Thin In house records monthly and promptly file the thinning in the resident's In house Overflow file in an organized manner where hard copy health records are maintained
- Maintain current resident information in the computer file and generate the necessary reports in accordance with the established schedule
- Assist the Health Information Designee/Director in maintaining the health information services for the facility in accordance with the current laws and regulations, and professional practice standards
- Follow the Assignment of Job Duties defining the various duties of the health information department staff.
Education
Certificate - Pharmacy Technician
American Career College
Los Angeles, CA06.2011
High School Diploma -
Hollywood High School
Hollywood, CA06.2008
Skills
- PCC Proficiency + ICD-10 Coding
- Clinical Documentation
- Records Administration
- Department Oversight
- Records Management
- HIPAA Knowledge
- Privacy Regulations
- Multitasking
- Attention to Detail
Accomplishments
- Employee of the Month for October 2021
- Employee of Year 2021 at Palazzo Post Acute
Languages
English
Native or Bilingual
Tagalog
Native or Bilingual
Preferences
Kristina De Los Santos, Palazzo Post Director of Nursing
(310) 402 - 7785
Health Penera, Beecan Health Information Consultant
(310) 531 - 0308
Avenia Nazarian, Business Office Manager
(818) 606 - 1841
Timeline
Medical Records Director
CALIFORNIA POST ACUTE
2023.03 - Current
Medical Records Specialist
PALAZZO POST ACUTE
2018.03 - 2023.03
Certificate - Pharmacy Technician
American Career College
High School Diploma -
Hollywood High School
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